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Select One: Q] Citibank MasterCard@ or LI Citibank Visa®
Please use ballpoint pen.



Print full name First Middle Initial Last Name of School I I ( ( I I I I I I IBac
as you wish it to (do not abbreviate) I I I I Bac
appear on card Your Address at School
Social I I I I I lDate of Mo Day Yr Number and Street 1 1 1 I {
Security Number I Birth (lll l if different from permanent address) l i 1 1 1
PraetI I I I III I I 11 11 1 1 CIFt0W jI, i I I I ~I I I I I Ct onZ
Ciy.TwndressI I tae Zp YuPoneurnti dreSt edCr i
or~~~~~ost~~,'OfhcII I I I I I I l i i IId I I Area ICodeacho I I{ Sae nt[ieraet L~ho
PermaTho n e(I I I I I Nam Tha I I I I ISte I I IZi or1 AePhn
PanetPo d Area Code ( ) I I I pero~oetlj I I I I I I
Name That I Your class QZ Freshman QZ Sophoniore
Appears on Phone ill I I I I I I I I I I I I QEJunior QliSenior QEGraduate Student Q FacultyStaff QlOther ________
U.S. Citizen? Ql Yes If No, Are You Ql Yes Major Ql Full-Time Student
[]No A Permanent Resident? Qi No QI Part-Time Student
AnulSource(s): Ql Allowance/Savings Q] Summer Job Pleas, include a copy of one of the followin so that your application can be processed immediately.
nnual. $ Salary/Stipend D] Paid tuition binl for current semester LiValidated Student ID with Currant Enrollment Sticker
Name of Employer (Present.
Future or Previous/Summer) 5 - !
Employer Telephone f I I I I I I IBy signing below I authorize Citibank (South Dakota). N.A. to check my credit history and eachange
a i information about howlI handle my account with proper persons and with credit bureaus itt1 am issueda
and Area Code 1 ) II I Icard. I authorize my employer, my bank. and any other references listed above to release and/or verily
MnyMarket Account Number Bank Name intormation to Citibank (South Dakota), N.A. and its affliiates in order to determine my eligibility for the
MoneyCitibank credit card, t am aware that information gathered about me is used to determine my eligibility for
(Joint or Individual) the credit card account and any renewal or future extension of credit. If t ask. t will be told whether or not
consumer reports on me were requested and the names of the credit bureaus, with their addresses, that
Savings Account Number Bank Name provided the reports. If I permit my spouse to use my card. I understand that account information wilt also
(Joint or Individual) be reported to credit bureaus in my spouse's name. I certify that l am 18 years o1 age, or older, and that the
information provided is accurate. I understand that if I use the card or authorize its use or do not cancel
Checking Account Number Bank Name my account within 30 days after I receive the card, the Citibank Agreement sent to me with the card wilt
(Joint or Individual) be binding on me. Terms are subject to change.
*You need not include spouse's income, alimony, child support or separate maintenance payments paid In order lo be considered for a Citibank MasterCard or a Citibank Visa card you must complete and
to you if you are not relying on them to establish creditworthiness sign this application. Omisions of any of the knfontnatlon requested i this apitonmay be grounds
for denial. I verify that I have read and understand the disclosure boa on the bc.Ple=s do not send
payment of $2 annual lee; you wilt be billed later.
X

EB4423-B1

Applicant's Signature Date
To ensure that your application is processed as quickly as possible, please complete all
t he information requested and mail to: Citibank (South Dakota) N.A., Citicorp Credit
Services, Inc. (MD), One Citicorp Drive, Hagerstown, Maryland 21748-0002.